Out-of-Area Logic in Healthcare Claim Adjudication: Framework and Implementation
Author(s): Praveen Kumar Vutukuri
Publication #: 2412071
Date of Publication: 08.09.2020
Country: USA
Pages: 1-12
Published In: Volume 6 Issue 5 September-2020
DOI: https://doi.org/10.5281/zenodo.14507599
Abstract
The healthcare claim adjudication process is a critical component of healthcare systems, ensuring fair reimbursement for services rendered to patients. The "Out-of-Area" (OOA) logic plays a pivotal role in adjudicating claims from providers or patients outside the designated geographic coverage of a health plan. This paper explores the framework, implementation, and challenges of OOA logic in healthcare claim adjudication, providing detailed calculation and automated workflow for real-time processing. We propose a methodology to streamline OOA claim processing while adhering to plan policies and maintaining efficiency.
Keywords: Healthcare Claims, Adjudication, Out-Of-Area Logic, Healthcare Reimbursement, Automation, Geographic Coverage, Payer Policies.
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